Second Year Nursing Skills

True The client who is immobilized for the next 4 months is at risk for developing pneumonia. The following would be an accurate nursing diagnostic statement: "Risk for Infection related to inadequate primary defenses: stasis of secretions." True or False Risk for infection A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis for the most immediate health risk would be: risk for infection fever anxiety impaired social interactions the need to use the strictest isolation precautions possible when devising a care plan for a client who requires isolation precautions, the nurse needs to take into consideration all of the following EXCEPT -the need to use the strictest isolation precautions possible -the individual's need for stimulation -the frequency with which staff will be able to interact with the client -the client's potential feeling of inferiority because of the presence of the infection sterile items are 2 inches away from the edge of the field the nurse determines that a field remains sterile if which of the following conditions exist? -the field was set up 1 hour before the procedure -the nurse reaches over the field rather than around the edges -sterile items are 2 inches from the edge of the field -tips of wet forceps are held upward when held in ungloved hands -the container of a stool specimen he leaves in the designated area for transport to the lab is visibly soiled on the outside -he expects special garbage bags at every bedside which of the following indicate(s) that Peter does not have a good understanding of basic strategies for preventing transmission of infectious agents? -he handles soiled linens with minimal manipulation -the container of a stool specimen he leaves in the designated area for transport to the lab is visibly soiled on the outside -he expects special garbage bags at every bedside -he cleans the blood pressure cuff between using it on his clients -she removes her mask to scratch her nose, then replaces it -she considers her eyeglasses to be appropriate eye protection -she removes her gloves and does not perform hand hygiene between leaving one room and going into the other room which of the following indicate(s) that Sharon is at risk for exposing herself or others to infectious agents when caring for her two clients who are on droplet and contact precautions? -she removes her mask to scratch her nose, then replaces it -she is careful not to touch the front of her gown when providing care and removing the gown -she considers her eyeglasses to be appropriate eye protection -she removes her gloves and does not perform hand hygiene between leaving one room and going into the other room colonization means that resident flora cause damage to the host tissue, resulting in the signs and symptoms of infection A nurse is evaluating a nursing student's understanding of types of infections. which of the following statements demonstrates a need for further teaching? -a UTI is an example of a local infection -colonization means that resident flora cause damage to the host tissues, resulting in the signs and symptoms of infection -a surgical site infection caused by the bacteria from the client's own intestine is an example of an infection that originates from an endogenous source -health-care-associated infections are classified as infections that are associated with the delivery of health-care services in a community setting or a health-care facility, although they may only appear after the client has been discharged from a facility skin coagulase-negative staphylococci, propionibacterium acnes, staphylococcus aureus and corynebacterium zerosis are normally found where intestine enterococcus species, enterobacteriaceae, escherichia coli are normally found where oropharynx and/or mouth streptococcus species, lactobacillus species, and yeast are normally found where carrier a person or animal that harbours a specific infectious agent and serves as a potential source of infection yet does not manifest any clinical signs of the disease is a : -carrier -vehicle -vector -parasite direct contact type of transmission from kissing indirect contact type of transmission from sharing a cigarette droplet type of transmission from spitting airborne type of transmission from inhaling dust particles vector-borne type of transmission from being bitten by an infected mosquito vehicle-borne type of transmission from playing with toys at a daycare centre fecal-oral route type of transmission from drinking contaminated water coughing and sneezing are associated with.... most microorganisms transmitted by the droplet route... an infection-control practitioner is assessing a nurse's understanding of modes of transmission. Which of the following indicate that further teaching is necessary? Select all that apply. -most microorganisms transmitted by the droplet route can also be transmitted by the airborne route if the droplets dry out and become droplet nuclei -coughing and sneezing can be associated with indirect contact transmission because infectious respiratory secretions can contaminate the local environment -coughing and sneezing are associated with droplet transmission because large droplets (>5 microns) containing infectious agents can land directly on mucous membranes of a recipient if that person is standing farther than 3 meters away -all microorganisms transmitted by the airborne route can also be transmitted by the droplet route everything but gender the client is an 80 year old diabetic man with acute leukemia. which of the following factors predispose this client to infection? -his chemotherapy meds for bone marrow suppression -his age -his diabetes -his gender anticancer medications depress production of leykocytes in bone marrow corticosteroids inhibit the inflammatory response antibiotics kill resident flora allowing growth of pathogenic strains insertion of an IV breaks skin and allows microorganisms to enter sterile space hand hygiene and good personal hygiene... fever in children should be monitored closely... a nurse in the pediatric setting is assessing a nursing student's understanding of infection and children. which of the following show that the student has a good understanding? check all that apply -hand hygiene and good personal hygiene are important in preventing infection in pediatric settings -good nutrition and hydration are not important in preventing infection in children -fever in children should be monitored closely because they are at higher risk of fever-induced seizures than adults -breast-fed infants have a higher risk of infection than formula-fed infants HIV which of the following is an infectious agent for which a health-care worker should seek treatment as soon as possible after exposure -hep B -hep C -HIV -MRSA get help to keep Mr James calm so he wont' make any sudden movements that could jar her hand Sarah has to start an IV on Mr. James, who is a slightly confused older adult with a respiratory infection that will be treated with IV antibiotics. Which of the following represents the best way for Sarah to prevent a sharps injury when performing venipuncture on Mr. James? -get help to keep Mr James calm so he won't make any sudden movements that could jar her hand -recap the needle as soon as she has removed it from the vein -wear sterile gloves when she performs venipuncture -wash her hands before beginning the procedure ... the result of a client's blood culture reveal an infection throughout the blood stream. This is known as a _ and indicates a systemic infection disinfectants and antiseptics often have similar chemical components, but the disinfectant is a less concentrated solution which of the following statements is incorrect? -a disinfectant is a chem preparation, such as phenol or iodine compounds, used on inanimate objects -disinfectants and antiseptics often have similar chem components, but the disinfectant is a less concentrated solution -a disinfectant is an agent that destroys pathogens other than spores -disinfectants are frequently caustic and toxic to tissues -has not received the vaccine against the pneumococcal bacteria -received a flu shot two years ago after evaluating a 75-year-old client's chart, the nurse concludes that he is at risk for acquiring a respiratory illness this year. what evidence supports this conclusion -has not received the vaccine against the pneumococcal bacteria -has not received the hep b vaccine -last tetanus booster at age 50 -received a flu shot two years ago mode of transmission remove globes and perform hand hygiene after emptying a bedpan-which part of the chain of infection does this alter portal of entry wear a mask and eye protection when emptying a container that will splash -intervention that can alter the link of which part of the chain of infection reservoir, etiologic agent, mode of transmission, portal of exit, portal of entry, susceptible host the six links in the chain of infection infection prevention teach clients how to reduce their susceptibility and exposure to infectious agents infection control instruct the client to perform hand hygiene and use barrier precautions at the appropriate time vasodilation caused by chemical mediators at the site of damage the nurse notes hyperemia when evaluating the incision of a client. the nurse knows that this indicates what events in the inflammatory response? exudate formation the inflammatory response occurs in three stages. in what stage does fibrinogen, thromboplastin and platlets form to make a barrier? -exudate formation -reparative phase -cellular responses -vascular responses both are activated by, and react with, their specific antigens on target cells macrophages and cytotoxic T cells are similar in all but which one of the following? -both are activated by, and react with, their specific antigens on target cells -both help defend against bacterial infection -both help defend against viral infections -both result in damage to target cells and initiate the inflammatory response